膽道胰腺疾病介紹課件

膽胰惡性腫瘤與黃疸

膽胰惡性疾病——keypoint樹立壺腹周圍癌的概念癥狀:典型的梗阻性黃疸(皮膚黃染\白陶土樣便\全身瘙癢)影像學特征：復雜性，往往沒有明顯的占位性改變,診斷依靠間接征象。對造成胰腺癌癥狀和低切除率的解剖學因素加以了解膽胰惡性疾病的診斷思路

SpleenBoneMarrowSenescentRedCells80~85%IneffectiveErythropoiesis15~20%Hemoglobin

HemeGlobinReticulo-endothelialsystem

UnconjugatedBilirubinALB-boundbilirubinPlasmaUnconjugatedBilHepaticHemoproteinsConjugatedBilirubinLiverUDPGTBilirubin:4mg/kg/dUptakeConjugationExcretionTransportationProductionBilirubinMetabolism*

UnconjugatedBilUnconjugatedBilirubin

KidneyUrineSmallintestineBileduct

Stool80-85%UrobilirubinStercobilinPortalvein

Urobilirubin15-20%UrineUrobilirubin

2%Bilirubinproduct

UnconjugatedbilirubinConjugatedbilirybinUrobilirubin,stercobilin

EnterohepaticCirculationofBilirubin

ColonBacteria

UnconjugatedBilirubin10%Urobilirubin*LiverClinicalClassificationofHyperbilirubinemiaPredominantUnconjugatedHyperbilirubinemiaPredominantconjugatedHyperbilirubinemiaMixedHyperbilirubinemia

PredominantUnconjugatedHyperbilirubinemia1.Overproduction

Hemolysisduetoavarietyofetiologies, e.g.,hemolyticjaundice

Ineffectiveerythropoiesis e.g.,megaloblasticanemia2.Decreasedhepaticuptake

Gilbertsyndrome,etc.

Drugs:rifampin,etc.

Neonataljaundice

1.Intrahepaticcholestasis

Cholestatichepatitis:viral,alcoholic,auto- immunehepatitis

Drug-induced:androgens,estrogens,cyclo-sporins,thiouracils,phenothiazines,captopril

Pregnancy

SepsiswithGramnegativeorganisms

Primarybiliarycirrhosis(PBC)

Inheritary:Dubin-Johnson,RotorsyndromesPredominantConjugatedHyperbilirubinemia2.Extrahepaticbiliaryobstruction

Gallstones

Tumors:pancreatic,bileduct,ampulaofVater

Bileductcompression:chronicpancreatitis,lymphnodes

Post-operativebiliarystricture

Primarysclerosingcholangitis(PSC)

CongenitalbiliaryatresiaPredominantConjugatedHyperbilirubinemiaDuetohepatocellulardiseaseordamage

Hepatitis:viral,alcoholic,autoimmune

Cirrhosis,Wilson’sdisease

Sepsis

Congestiveheartfailure,Budd-Chiarisyndrome

Drug-inducedhepaticinjury:alcohol,rifampin,cimetidine,sulfonamide,colchicine,verapramil,etc.

MixedHyperbilirubinemiaDecreased

bileacidexcretion

Pruritus

Absorptionoffat&fat-solublevitamins

Coagulopathy:dueto

VitKdeficiency

CalciumabsorptionandosteoporosisHypercholesterolemia,xanthomaIncreased

synthesisandsecretion

ofcanalicularenzymes:ALP,GGTConsequencesofSustainedHyperbilirubinemiaRenalfailurePigmentgallstonesIncreasedpostoperativemortalityandmorbidityKernicterusininfantsDecreasedcardiovascularresponsetovasopressorsConsequencesofSustainedHyperbilirubinemiaDistinctionbetweenintracellularandextrahepaticcholestasis

Intrahepatic

ExtrahepaticUS,CT,Extra-&intra-

Extra-&intrahepatic

hepaticbile

bileducts

dilated,

ductsnormal

ERCP:stones,ERCP

normaltumors,

stricturesALP,GGT

~Auto-Abs

AMA,M2+-+++

Inspecificauto-AbsforPBC

forPSCSiteofHepatocytes

and

Extrahepaticbile

lesions

canaliculi/ductules

ductsLaboratoryDifferentiation

ofJaundice

History,PhysicalExaminationHb,Bloodcells,Bil,ALT,Alb,ALP/GGT,PT+A,HBsAg,Urine,StoolPredominantunconj.bil.

MixedPredominantconj.bil.MarkersforviralhepatitisImmunologicaltestsMicrobialexaminationSystemicdiseasesLiverbiopsyifnecessaryUltrasonographyExtrahepaticbileductsnotdilatedExtrahepaticbileductsdilatedCTERCPMRCPPTCTestsforhemolysisBonemarrowLiverbiopsyifnecessarySummary:ApproachestoDiagnosisofJaundice*膽胰惡性腫瘤的影像學表現(xiàn)膽胰疾病的特殊檢查超聲檢查：膽囊疾病的金標準CTMRI各種造影檢查：PTCD與ERCPPTCD與ERCP涵義適應(yīng)證：診斷價值基本被無創(chuàng)方法取代，已經(jīng)傾向于疾病的治療有創(chuàng)性：可導致致命并發(fā)癥膽管癌-間接征象胰腺癌-模糊的占位效應(yīng)膽胰惡性腫瘤的有關(guān)解剖膽道解剖-肝外膽管分部膽總管分部膽總管與胰管vater氏壺腹，oddi氏括約肌胰腺解剖人體第二大腺體頭頸體尾四部分+勾突主胰管與副胰管由腹腔干供血為主，靜脈回流入門靜脈

return胰腺生理獨特的、以血糖調(diào)節(jié)為主的內(nèi)分泌功能：A與B細胞超強的外分泌功能，負責三大營養(yǎng)素的代謝急性胰腺炎時可以導致自身的消化并產(chǎn)生炎性介質(zhì)危及全身橫結(jié)腸空腸下腔靜脈

膽總管右膈腳降結(jié)腸胰頭右腎胰頸腸系膜上靜脈腸系膜上動脈腹主動脈左腎

胰頭、胰頸、腸系膜上靜脈斷層胰頭下腔靜脈十二指腸降部鉤突腎竇膽囊腎門腹主動脈腸系膜上動脈腸系膜上靜脈空腸胰頭、腸系膜上靜脈斷層膽胰惡性腫瘤的鑒別診斷膽胰系統(tǒng)重要疾病-共性疾病炎癥：急慢性膽囊炎，膽管炎，急慢性胰腺炎腫瘤：膽管癌，膽囊癌，胰腺癌，壺腹癌先天性疾?。耗懣偣苣夷[，胰腺囊腫膽胰系統(tǒng)重要疾病-特殊疾病結(jié)石疾?。耗懩医Y(jié)石與膽、胰管結(jié)石胰腺內(nèi)分泌腫瘤：功能性與無功能胰腺內(nèi)分泌腫瘤膽囊息肉、膽囊結(jié)石與膽囊癌膽囊結(jié)石的成因：脂質(zhì)代謝異常造成的膽固醇過飽和癥狀與其造成的多種并發(fā)癥有關(guān)膽囊結(jié)石與膽囊癌

膽囊炎、膽管炎、梗阻性黃疸、膽源性胰腺炎、膽囊十二指腸瘺膽囊疾病與膽囊息肉樣病變定義分類：手術(shù)適應(yīng)癥獨特的膽固醇性息肉炎性息肉腺瘤性息肉腺肌癥惡性息肉膽囊疾病與腹腔鏡膽囊切除術(shù)：微創(chuàng)外科與胰腺膽道手術(shù)1987年問世外科技術(shù)的重大革命胰腺腫瘤的局部切除是最佳的適應(yīng)癥（eneucleation）胰體尾手術(shù)成為常規(guī)重建仍然是弱項重要疾病一：膽囊疾病與膽石癥膽囊的分部：Hartmann袋，螺旋瓣Calot三角：是由膽囊管、肝總管、肝臟下緣所構(gòu)成的三角區(qū)。其內(nèi)有膽囊動脈、肝右動脈、副右肝管通過。膽石癥：膽固醇、膽色素與混合結(jié)石

認識一下慢性胰腺炎酒精、膽道疾病為主要病因胰腺內(nèi)外分泌功能的喪失胰腺內(nèi)分泌腫瘤重要疾病五：胰腺內(nèi)分泌腫瘤胰腺獨有的腫瘤如何與外分泌腫瘤鑒別胰島素瘤和無功能胰島細胞瘤發(fā)病率較高Whipple三聯(lián)癥：與血糖關(guān)系密切膽胰惡性疾病的治療惡性疾病的胰十二指腸切除術(shù)壺腹周圍癌的經(jīng)典手術(shù)方式復雜的切除與重建工作：涉及膽、胰、胃等臟器的切除與重建梗阻性黃疸造成的凝血機制障礙、全身營養(yǎng)不良加重了手術(shù)難度，術(shù)后易發(fā)生腎功能衰竭、低氧血癥治療（掌握）腫瘤侵及門靜脈、腸系膜上靜脈者可將其一段血管連同腫瘤切除，再行血管移植吻合行全胰切除術(shù)。對不能切除的胰腺癌，為了解除黃疸，有條件者首先爭取作內(nèi)瘺。膽胰惡性疾病的輔助治療疼痛：疼痛的階梯治療第一階段輕度疼痛，非阿片類鎮(zhèn)痛藥（阿司匹林、布洛芬、對乙酰氨基酚）

第二階梯在輕、中度疼痛時，弱阿片藥物（可待因、強痛定等）

第三階梯選用強阿片類藥，代表藥物是嗎啡、杜冷丁等。其選用應(yīng)根據(jù)疼痛的強度(如中、重劇痛者)而不是根據(jù)癌癥的預(yù)后或生命的時限。常用緩釋或控釋劑型CaseDiscussion(1)A30y.o.femalepatientwasadmittedbecauseofanorexia,fatigue,andpainoverrightcostalareafor2weeks.HermotherwasdiagnosedasacutehepatitisBsixweeksago.P.E.revealedjaundiceoverscleraeandat